Nokea
The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect to find the presence of:
- A. Mongolian spots
- B. Scrotal rugae
- C. Head lag
- D. Polyhydramnios
Correct Answer: C
Rationale: Head lag is expected in a preterm newborn at 32 weeks due to underdeveloped neck muscle strength.
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A client is transferred to the intensive care unit following a conornary artery bypass graft. Which one of the post-surgical assessments should be reported to the physician?
- A. Urine output of 50 ml in the past hour
- B. Temperature of 99°F
- C. Strong pedal pulses bilaterally
- D. Central venous pressure 15 mmHâ‚‚O
Correct Answer: D
Rationale: A central venous pressure of 15 mmHâ‚‚O is elevated, indicating potential fluid overload or cardiac issues, requiring reporting.
Which of the following postpartal clients is at greatest risk for hemorrhage?
- A. A gravida 1 para 1 with an uncomplicated delivery of a 7-pound infant
- B. A gravida 1 para 0 with a history of polycystic ovarian disease
- C. A gravida 3 para 3 with a history of low-birth weight infants
- D. A gravida 4 para 3 with a Caesarean section
Correct Answer: D
Rationale: A gravida 4 para 3 with a Caesarean section is at higher risk for hemorrhage due to uterine atony from multiple pregnancies and surgical delivery.
A 5-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
- A. Periorbital edema
- B. Tenseness of the anterior fontanel
- C. Positive Babinski reflex
- D. Negative scarf sign
Correct Answer: B
Rationale: Tenseness of the anterior fontanel indicates increased intracranial pressure, a critical finding in bacterial meningitis in infants.
The nurse is monitoring a client’s EKG strip and notes coupled premature ventricular contractions greater than 10 per minute. The nurse should expect to administer which of the following?
- A. Atropine sulfate (Atropine) IV.
- B. Isoproterenol (Isuprel) IV.
- C. Verapamil (Calan) IV.
- D. Lidocaine hydrochloride (Xylocaine) IV.
Correct Answer: D
Rationale: Lidocaine is the drug of choice for frequent premature ventricular contractions (PVC) occurring in excess of 6-10 per minute; for coupled PVCs or for a consecutive series of PVCs that may result in ventricular tachycardia
A client's admission history reveals complaints of fatigue, chronic sore throat, and enlarged lymph nodes in the axilla and neck. Which exam would assist the physician to make a tentative diagnosis of leukemia?
- A. A complete blood count
- B. An x-ray of the chest
- C. A bone marrow aspiration
- D. A CT scan of the abdomen
Correct Answer: A
Rationale: A complete blood count (CBC) is the initial test for leukemia, revealing abnormal white blood cell counts, anemia, or thrombocytopenia, supporting a tentative diagnosis.